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VA » Health Care » PTSD: National Center for PTSD » Providers » Treatment » Anniversary Reactions and Other Recurring Trauma Reminders

PTSD: National Center for PTSD

Anniversary Reactions and Other Recurring Trauma Reminders

Sadie E. Larsen, PhD

A key symptom of posttraumatic stress disorder (PTSD) is reactivity to trauma-related cues. Such reminders (also referred to as "triggers") are often unexpected and unforeseen. But trauma-related cues can also be anticipated and linked to a particular recurring moment in time. Such anniversaries can be memorialized as a meaningful time to remember, or they could come to be anticipated with anxiety. Some are publicly shared trauma reminders, such as the anniversary of Hurricane Katrina or of the terrorist attacks on September 11. Other anniversaries are private and sometimes unknown by others, such as the death of a loved one or the date of a prior sexual assault. This article focuses on anticipated, time-linked trauma cues, whether public (e.g., military-related holidays, fireworks on the 4^th of July), or personal (e.g., anniversaries of traumatic deaths or other traumas).

Though there is scant empirical research on recurring trauma reminders, the broader literature provides a context for understanding why people may find such anniversary cues to be particularly difficult. This article describes such reactions and offers suggestions to support patient self-care and symptom management.

In This Article

What contributes to recurring trauma-related distress? Can recurring reminders prompt growth? How common is distress around recurring trauma reminders? How can clinicians help? Summary Resources for Patients References

What contributes to recurring trauma-related distress?

For people with PTSD, distress often occurs when a cue is presented that is in some way related to the memory of the initial trauma; this is the case whether trauma cues are expected (anniversaries) or unexpected (unanticipated environmental cues). Even vague similarity to a cue present at the time of the trauma can lead to a heightened distress and survival response in a very different later context because the trauma reminder is stored in memory as an indication that there is impending danger. At times this happens without the person even being aware that they have made the connection between the trauma and a particular cue in the current situation (1).

As opposed to unexpected trauma cues, "anniversary reactions" refer to increases in distress related to a specific date, most often the date the trauma occurred or a date connected to the trauma (e.g., birthday of someone who was killed). Anniversary reactions can occur during specific events such as birthdays, holidays, and other times during which a loved one may be particularly missed. Anticipated trauma cues might also include the dates of collectively experienced events such as September 11, military-related holidays (Memorial Day or Veterans Day), or individually relevant dates, times or cues related to a specific trauma.

Anniversaries can be particularly salient trauma reminders because of media attention (in the case of public events) or increased amounts of meaningful trauma reminders (in the case of private events). Trauma-related distress can be amplified by the fact that trauma reminders are expected and so may be anticipated with anxiety or dread. In the case of the first anniversary of a death (whether traumatic or not), it is well known that this can be a difficult time, so people may worry ahead of time that they will struggle and thus be alert to any indications of that being the case. Media exposure can also amplify trauma-related distress around collectively experienced dates, contributing to a cycle of media consumption and increased worry about future events (2,3).

The 4^th of July is a date that can bring up distressing memories in people who have experienced gun violence, combat, mortar attacks, etc. Fireworks, whether expected on the 4^th or unexpected at other times, can exacerbate startle responses, increase hyperarousal, and bring up intrusive recollections of combat or other gun-related trauma experiences. Those who are sensitive to fireworks may also come to dread that date each year, adding a layer of hypervigilance before the date as well.

Anniversaries may also be times when people consciously think about how their lives have changed or make judgments about themselves (e.g., "What is wrong with me that I'm still bothered by this?" or "I can't believe I forgot about such a meaningful day," or "I used to love fireworks"). Such appraisals can contribute to increased secondary emotions (e.g., shame, anger about being bothered) that can then prolong the initial reactions.

Can recurring reminders prompt growth?

Finally, some authors have also theorized that anniversary reactions may indicate normal reactions to grief unfolding over time (4). That is, with the understanding that grief may not be linear or time-limited, anniversaries are times that tend to remind the mourner of the lost loved one and invite them to process their grief more fully. If new experiences or appraisals can be associated with the memory, these may even be times of growth or positive change (5). For instance, the first anniversary of September 11 was viewed by some as a time to mark closure and to come together as a community (6). Because such public events are communally shared and widely publicized, distressing reminders may be more common due to media coverage. But public events also afford an opportunity for social support, sharing of memories, and a sense of collective experience. It has been suggested that when such events can foster the potential for collective action, advocacy and healing, this can be particularly meaningful for communities of color in responding to racially related trauma (e.g., the killing of George Floyd; 10).

How common is distress around recurring trauma reminders?

Empirical studies of recurring traumatic reminders are rare, especially longitudinal studies (but see 8). Most studies have included small or anecdotal reports of convenience samples finding some increase in distress at the time of the trauma anniversary (9-12).

A set of small studies examined longitudinal anniversary reactions following military trauma (13,14). Two years after deployment, 59 Veterans were asked when their worst trauma took place, and when in the last year had been their worst months. 31% of the sample experienced an anniversary reaction (i.e., their worst month was the month of the trauma). Of the 6 participants in the sample who had PTSD, all of them had experienced anniversary reactions. In a follow up 6 years later with a subset of these Veterans, many continued to experience anniversary reactions. When spouses were separately asked, their reports aligned with Veteran reports (even without knowing the dates of their spouses' traumas). In some cases, spouses reported anniversary reactions that had not been identified by Veterans, and when asked about this discrepancy, Veterans indicated that their spouse's report was likely more accurate.

How can clinicians help?

Recurring trauma reactions can encompass a wide spectrum of cognitive, behavioral or somatic symptoms. It can be difficult to pin down what feels different about these time-linked or memorial trauma reminders versus spontaneous trauma cues. A case conceptualization and exploration approach can be helpful in identifying what is driving the distress. Chain analysis may be one way of helping patients to gain clarity about what reactions, appraisals or cues may be contributing to the distress (15). For some, PTSD symptoms may be primary, with reactions mapping on to the typical symptom clusters of PTSD. Indeed, Morgan et al (1999) found that the most typical reactions during trauma anniversary months were intrusive memories and reactivity to them, avoidance of memories, emotional numbing, hyperactivity, irritability, and sleep disturbance (14). Others may be more bothered by grief, depression, or a general sense of feeling stuck and unsure how to move forward.

The table below outlines clinical suggestions to consider depending on what may be driving the reactions, though many suggestions will apply to more than one presentation.

Table 1. Clinical Suggestions to Address Recurring Trauma Reminders

Symptom Presentation or Etiology	Suggestions for Providers to Consider With Their Patients
General distress	Discuss the fact that anniversary reactions are normative and can be treated as such, especially if short-lived and gradually decreasing over time. Indeed, the goal is to be able to remember an event with a full range of emotions but without a significant and sustained functional impairment in doing so. Promote general self-care in the time leading up to an anniversary (e.g., exercise, sleep, good nutrition). Promote social support by encouraging patients to let people know that a challenging day is approaching and how they might be helpful. In the case of public events, encourage thoughtfully minimizing media consumption. Consider the use of free publicly accessible self-help mobile apps such as PTSD Coach or Mindfulness Coach. Encourage healthy, planned breaks before returning to the stressful situation. This could include positive distracting activities (e.g., listening to music, going for a walk, spending time in nature, playing games). Consider the use of Skills for Psychological Recovery as a framework for promoting healthy adaptation to stress. Anniversaries may be a time to make some meaning, whether by marking the occasion, reflecting on positive changes in life, or helping others (e.g., giving blood, making a charitable donation).
Treatment History
Patient has successfully completed treatment and generally is not bothered by PTSD symptoms other than on a specific anniversary	Discuss how tools previously learned in therapy (e.g., worksheets, exposure skills) can be helpful in managing any temporary increases in symptoms. Help to normalize that even after successful PTSD treatment, hypervigilance is somewhat less likely to resolve, so it may be helpful to develop strategies for accepting and soothing arousal rather than expecting it not to occur. Consider the thought (without needing to respond), "I may be uncomfortable in this moment, but it is temporary. I am safe."
Patient either has not had treatment or has had some treatment but continues to have significant PTSD symptoms, both at anniversary times and other times	Consider whether the anniversary reaction is an indication that (a new course of) therapy may be beneficial. Trauma-focused therapy may help the patient to better make sense of what happened to them and why it might be related to intrusive memories in the present, and to find new ways of seeing the event so that it no longer intrudes so readily into the present.
Specific PTSD Symptom Clusters
Intrusions	First, identify trauma cues, including those that may be less obvious to the patient. Chain analysis may be helpful. Next, practice stimulus discrimination, i.e., outlining ways in which the current situation is different from the situation in which the stimulus first arose, with the patient reminding themselves of those differences when cues arise in the present (16). Consider having the patient write down both cues and alternative responses to make new responses easier to access.
Avoidance	Help find ways to incorporate gradual, repeated exposure—whether to the memory itself or to common trauma cues that lead to reexperiencing symptoms. Find ways to encourage living a life driven by self-identified values rather than letting fear of a trauma reminder drive actions
Numbing, negative thoughts	Find small, manageable ways to engage in pleasant activities or connect to emotion (e.g., spending time with their child). See Skills for Psychological Recovery worksheets for pleasant activity ideas. Consider encouraging "acting as if" a patient is enjoying an activity—with behavioral activation, emotion is likely to follow behavior. Find self-talk that works (e.g., "This stress will be temporary and doesn't mean there's something wrong with me.").
Hyperarousal, irritability	Practice using relaxation skills (e.g., breathing, progressive muscle relaxation, visual imagery) or grounding (e.g., focusing on the breath or the five senses; focusing on strong physical sensations like eating a strong mint or holding a piece of ice). See PTSD Coach mobile app. If a patient has appraisals such as, "This feeling means I'm in danger," discuss "emotional reasoning" and determining how to accurately identify danger. A reframe might be: "Even though I feel in danger, that is a product of the way my brain is wired to try to protect me—I can talk myself through it. Memories are not dangerous." If experiencing increased irritability, consider using any anger management skills that have otherwise been helpful, including the AIMS mobile app. Consider reframing any thoughts that suggest, "Other people are being inconsiderate," or "...trying to irritate me."
Other Emotional Distress
Grief, sadness	Consider whether a diagnosis of prolonged grief disorder is indicated, either with or instead of PTSD (noting that stress at anniversary times is not in and of itself indicative of a disorder; 17). Make sure the patient has given themselves adequate time to mourn (and that reminders of the loved one are not being avoided). Encourage patients not to judge themselves for mourning, acknowledging that it is a natural, long-lived, waxing and waning process that may differ across cultures. Encourage reconnection with others, either to talk about the loss or just to spend casual time together. Others often want to help but do not know how, so patients may need to directly communicate what they need. Consider using anniversaries as an opportunity to deepen recovery, promote healing (e.g., performing a meaningful ritual; visiting a grave; communicating with lost loved one through writing, conversation, or prayer), and commemorate the deceased loved one's life (18). Journaling or other creative expressions can be helpful (e.g., creating a scrapbook or writing down and releasing wishes for the future; 6).
Feeling a sense of emptiness, need to move forward	Consider whether there is room for recognizing or fostering posttraumatic growth (5). Identify meaningful values or goals and how to move toward them. (Re)connect to religion, spirituality, prayer or meditation. Consider a referral to a chaplain or clergy.
Exacerbating Factors
Anticipatory anxiety	Make a plan for the day to help "cope ahead." Help patients to describe likely trauma cues and likely reactions, decide ahead of time on coping skills, imagine the situation and rehearse their new response and reframed thoughts. Consider developing a written "coping card" with this plan. Consider whether some exposure ahead of time may be helpful (e.g., to videos of fireworks).
Negative appraisals of self or of symptoms	If a patient has appraisals such as "I can't believe I'm still so weak/crazy that I'm bothered by this," or "I can't stand this," discuss how to reframe these as temporary and normative increases in symptoms, thereby decreasing secondary emotions resulting from negative appraisals.
Note: Thanks to Mindy Marcus, PhD, Milwaukee VAMC and Skills for Psychological Recovery handouts.

Summary

Specific times of year can raise both distress and opportunities for meaning making among people with PTSD. Clinicians can help patients better understand and anticipate anniversary reactions or other recurring trauma reminders. Together they can identify what factors are leading to this distress in order to best know how to help the patient prepare and cope.

Resources for Patients

As noted above, a number of free, mobile apps may be useful for your patients when cued by trauma reminders. The following web articles intended for a public audience may also be useful to share:

References

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Pfefferbaum, B., Nitiéma, P., & Newman, E. (2019). Is viewing mass trauma television coverage associated with trauma reactions in adults and youth? A metaâ€analytic review. Journal of Traumatic Stress, 32(2), 175-185. https://doi.org/10.1002/jts.22391
Thompson, R. R., Jones, N. M., Holman, E. A., & Silver, R. C. (2019). Media exposure to mass violence events can fuel a cycle of distress. Science Advances, 5(4), eaav3502. https://doi.org/10.1126/sciadv.aav3502
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